Whose Life Is It, Anyway?

“Frequent fliers” raise treatment issues, for which there are no easy answers.

By Daniel Munoz, M.D. '04

This time she almost died.

However, when I encountered Veronique in her ICU room, she did not seem to appreciate that reality.

“I want a hamburger,” she said, casually sitting up in bed with her needle-scarred legs dangling off the side. She was breathing comfortably with her supplemental nasal oxygen tubes propped uselessly on her forehead.

Veronique is 28 years old, though she looks about 40. And I write this column feeling an odd tension of emotions. I tell her story knowing that by the time this publication reaches your kitchen counter, she may not be alive.

Veronique’s illnesses are not medical mysteries. Her eventual demise will not be the result of a rare, untreatable condition. We know precisely what she has and what course of treatment she needs.

Six hours before she looked at me and placed her dinner order, paramedics had rolled Veronique into the critical care bay in the Hopkins emergency room. She was in profound respiratory distress, with life-threatening electrolyte imbalances in her body. She required emergent hemodialysis, which she promptly received. As a substitute for her kidneys, which had long since been rendered inactive by years of high blood pressure, HIV infection and illicit drug use, dialysis removed the fluid in her lungs and cleared the excessively dangerous levels of potassium in her bloodstream.

Dialysis is not new for Veronique. For the past few years, she has had three scheduled outpatient dialysis sessions per week. The trouble has been her attendance record, and her behavior when she chooses to attend. A longtime crack addict, she regularly shows up high and just as frequently becomes verbally abusive toward staff and other patients. When she recently took a swing at a staffer, she was ordered to leave the facility and told she would not be welcomed back again.

My team’s experience on the inpatient side of her care has followed a similarly discouraging pattern. In the absence of an outpatient dialysis slot, Veronique comes to the E.R. when she gets short of breath. She is subsequently admitted for dialysis. For the first 48 hours, she is relatively cooperative.

But once she is dialyzed, her condition improves and she feels better. Shortly thereafter, she reverts to her baseline personality, showing disrespect and scorn toward nurses, medical technicians and her physicians. She curses. She yells. She makes unreasonable demands. She interferes with the care we attempt to provide others. These violations give us little choice but to administratively discharge her from the hospital (a nice way of saying “forcibly remove”) before we can connect her with resources that might actually make a real difference, like psychiatry and substance abuse specialists. 

Three days later, she’s back, having just smoked crack. The story repeats itself.

It is fashionable and morally relativist to assert that we have simply failed as her doctors, as we should be responsible for narrowing the gap between our therapeutic tools and a patient’s willingness to accept our interventions. This premise is a motivating one. It obligates us to continuously refine and adjust our method of communicating until we get through to a patient and to then enlist that individual in a plan of care.

But Veronique’s experience shows that not only is this premise naïve, it is also fatally flawed. Why? Because it relieves individuals of the obligation to take on some semblance of responsibility for their own well-being. We can point Veronique in the right direction, but she is an adult with decision-making capacity. Armed with the necessary  medical recommendations, she makes bad decisions that are tragically her own.

So why are she and I in this situation? There are factors beyond my failure thus far in getting through to Veronique, factors beyond her failure to thus far take commensurate responsibility for her life. For reasons that extend far beyond the scope of an 800-word column, the city of Baltimore is home to a citizenry often facing a jarring collision of social and medical pathologies.

If any part of staying healthy depends on having functional family support structures, safe neighborhoods outside the lethal clouds of drugs and guns, quality schools where kids have a chance to actually escape the poverty trap and a local economic infrastructure offering advancement rather then stagnation, then the medical cases we see here as residents come as no great surprise.

If for no other reason than to prevent Veronique and others from falling into such tragic circumstances, we have every obligation to make this and other American cities into safer, less destructive environments. And we have every obligation as doctors to tirelessly attempt to connect with every patient, hardened, unpleasant, or otherwise.

Whether Veronique then responds is up to her.

It may be too late for Veronique. Every time she leaves the hospital, I wonder whether I will see her alive again. I hope I do.

Dan Munoz is a third-year resident in the Department of Medicine.